The American Heart Association and the American College of Cardiology guidelines advocate an approach that relates major, intermediate, and minor cardiovascular risk factors to the planned procedure.2 For example, if a major cardiovascular predictor is present, nonemergency surgery should be delayed until risk factor modification has been accomplished.

Clinical predictors for a major adverse cardiac event include recent (<1 month) myocardial infarction, unstable angina, decompensated congestive heart failure, severe valvular heart disease, and significant arrhythmias. The presence of one of these major clinical predictors mandates postponement of any cosmetic surgical procedure.

Intermediate predictors include mild stable angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus (especially type I), renal insufficiency, and poor exertional capacity. Adequate cardiovascular fitness to undergo an elective procedure, especially office-based, can be estimated by the patient’s ability to climb one flight of stairs or walk one block on level ground without shortness of breath and/or angina. This equates to 4 METs (metabolic equivalents) in a completed exercise test.2

With respect to ischemic heart disease, it is advisable to wait at least 6 months after a myocardial infarction and/or revascularization, angioplasty, stent placement, or bypass before considering elective surgery.2 Patients with a coronary stent(s) are universally on at least one and often two platelet inhibitors (e.g., aspirin and clopidogrel). This therapy is important for the stents but is a contraindication to many surgical procedures. These platelet-active drugs should not be modified without involving the patient’s cardiologist/internist as acute perioperative stent thrombosis has been reported after discontinuation of antiplatelet therapy.3 On the other hand, if the patient has had coronary revascularization within 5 years and is asymptomatic, the risk of a cardiac event is decreased and does not normally require additional workup. If revascularization was performed more than 5 years previously or the patient is symptomatic, cardiac risk is increased and a more extensive evaluation is mandated.

Cardiac risk factor modification frequently includes beta blockade and cholesterol statin therapy throughout the perioperative period.4

With respect to pulmonary status, smoking, chronic obstructive pulmonary disease (COPD), reactive airway disease, and obesity are the major risk factors. As with cardiac evaluation, patients should be screened based on symptoms and exertional capacity. If they are asthmatic, the goal is to stabilize them and avoid an exacerbation. Pulmonary function tests are rarely indicated or useful for preoperative screening. Because cosmetic surgery is elective, there is an opportunity to implement smoking cessation in order to reduce pulmonary and thromboembolic complications and improve wound healing and flap perfusion. Maximum benefit, however, is probably not achieved until at least a month after smoking cessation. Shorter term smoking cessation actually causes some increase in pulmonary secretions.

The comorbidities in obese patients include atherosclerotic heart disease, adult-onset diabetes, congestive heart failure, systemic hypertension, cardiac arrhythmias, pulmonary hypertension, obstructive sleep apnea, gastroesophageal reflux (GERD), a predisposition to DVT, and sensitivity to narcotic analgesics. The excess adipose tissue on the chest and abdominal wall compresses the lungs. The resultant increased intrathoracic pressure is magnified by excessive adipose tissues within the peritoneal cavity leading to a further reduction in the functional residual capacity and total lung capacity. Asthma, chronic cough, and pulmonary fibrosis may be manifestations of GERD, another common accompanying effect of the increased intra-abdominal pressure of obesity. It is important to appreciate that following an abdominoplasty, with plication of the rectus abdominis muscles, intra-abdominal pressure is acutely increased, which exacerbates any preexisting pulmonary compromise. In addition, lower extremity venous flow is impeded by increased intra-abdominal pressure, creating venous stasis and an environment conducive to venous thrombosis. The physiologic changes imposed by rectus plication are often underappreciated and persist without concomitant weight loss. While the cosmetic result obtained with an abdominoplasty might give the perception of actual weight loss, the intraperitoneal fat remains and is compressed into a smaller space, exacerbating all the underlying pulmonary and venous stasis aberrations.5

As with cardiac risk factor stratification/modification, the risk of DVT is considered and mechanical and/or pharmacologic prophylaxis implemented as indicated. Risk factors for DVT include birth control pills or hormone replacement therapy, protein C or S deficiency, antithrombin III deficiency, lupus anticoagulant, factor V Leiden along with acquired risk factors that include smoking, diabetes, congestive heart failure, obesity, and history of prior DVT. A history of DVT superimposes additional risk on the intrinsic thromboembolic risk of the procedure.

Surgery-specific risks can also be stratified as high, medium, and low. High risks for DVT are prolonged procedures and those associated with significant blood loss or fluid shifts. Examples in plastic surgery include major flap procedures, abdominoplasties and/or lower body lifts, and large volume liposuction. Intermediate-risk procedures include facelifts. Blepharoplasty and excision of small lesions present a low risk for DVT.

The aggressiveness of DVT prophylaxis is dictated by preexisting risk factors superimposed on the inherent risk of the procedure. Using Virchow’s triad (endothelial damage, stasis of blood flow, and hypercoagulability) as a model, the latter two components of the triad can be addressed. Sequential compression devices are utilized when possible to prevent stasis and ideally are applied prior to initiation of the sedation/anesthetic. Neuraxial anesthesia (spinal and/or epidural) should be considered for abdominoplasty. Neuraxial anesthesia provides a sympathetic block that promotes venous return and decreases the likelihood of stasis and an environment conducive to thrombosis. In terms of hypercoagulability, pharmacologic prophylaxis is achieved with preincision prophylactic administration of subcutaneous heparin or factor Xa inhibitors such as enoxaparin (Lovenox) and fondaparinux (Arixtra).

Fasting from solid food should be at least 8 hours. Milk is allowable up to 6 hours before initiation of sedation. Oral medications may be taken with a sip of water up to the time of surgery. To increase patient satisfaction, decrease gastric liquid volume, and to decrease the risk of dehydration or hypoglycemia from fasting, we encourage clear liquids up to 2 hours before the anticipated anesthesia start time in the first patient of the day and 3 hours for all following patients. Even though the minimum fast time for clear liquid is 2 hours, this allows for timely induction of the subsequent patients should the earlier procedures be shorter than anticipated. Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. Gatorade or other clear liquid electrolyte sports drinks are attractive because the stomach empties many times faster after these than after water alone because they contain sugar and salt that accelerate absorption from the proximal gastrointestinal tract and the sugar also prevents hypoglycemia in patients who are on a diabetes medication.6

Pretreatment beginning the night before with H2 blockers such as ranitidine (150 mg po), especially in obese patients, should be considered. This class of drugs is inexpensive, available over the counter, and well tolerated.

Basic monitoring calls for compliance with the American Society of Anesthesiologists Monitoring Standards.7

1. Standard I

Qualified anesthesia personnel present throughout the procedure.

2. Standard II

Patient’s oxygenation, ventilation, circulation, and temperature shall be continually evaluated.

2.1 Oxygenation

Inspired gas: When an anesthesia machine is used, the concentration of oxygen in the breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm in use.

Blood oxygenation: During all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed. When the pulse oximeter is utilized, the variable pitch pulse tone and the low threshold alarm shall be audible.

3. Ventilation

During regional anesthesia (with no sedation) or local anesthesia (with no sedation), the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs. During moderate or deep sedation, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment. If invoking the preclusion option, a statement in the record to explain why is recommended.

4. Circulation

4.1 Continuous display of the electrocardiogram (ECG). A helpful intraoperative ECG montage is to use at least one precordial electrode (except in breast surgery). If the ECG monitor has only three leads, this is readily accomplished by placing the left leg lead into the V5 position–anterior axillary line in the fifth intercostal space–and monitoring lead two (right shoulder-left leg). This configuration results in a modified V5 lead and is considerably more sensitive for identifying ischemia than any other single lead.

4.2 Arterial blood pressure and heart rate determination and evaluation at least every 5 minutes. Cautious interpretation of the patient’s blood pressure is essential, especially when the blood pressure cuff is placed lower than the heart (e.g., around the calf in a patient who is in a semi-sitting position).8 Conversely, hypertension secondary to stimulation or inadvertent intravascular injection of local anesthetics with epinephrine can lead to intra- and post-op bleeding and wound hematoma as well as myocardial ischemia.

Perioperative treatment of blood pressure can help avoid ischemia as well as reduce intra- and post-op bleeding as well as bruising. In general, it is desirable to continue all cardiac and antihypertensive medications according to the patient’s normal regimen, as hypertension is much more likely to occur than hypotension during procedures performed under local anesthesia with intravenous sedation.

5. Body temperature

To aid in the maintenance of appropriate body temperature during all anesthetics, every patient receiving anesthesia should have temperature monitored when clinically significant changes in body temperature are anticipated or suspected.